Urinary Diversion Surgery

Mar 03 2009

Posted by: dolphinlover in My Nursing Student Life

Vocabulary :

Diversion – an act of rerouting or diverting the flow from normal pathway to create a new way

Anastomosis - the surgical union of parts and especially hollow tubular parts
Ileal – or ileum is the final section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. The ileum follows the duodenum and jejunum
Ostomy - A surgically-created opening in the abdomen for elimination of waste products (urine or stool).
Stoma - an artificial permanent opening especially in the abdominal wall made in surgical procedures
Reservoir – pouch, a space (as an enlargement of a vessel or the cavity of a glandular acinus) in which a body fluid is stored
Cystectomy - the removal of all or a portion of the urinary bladder
Neurogenic bladder - refers to dysfunction of the urinary bladder due to disease of the central nervous system or peripheral nerves
Neobladder - a pouch or false bladder which mimics the normal storage function of the urinary bladder.

Urinary Diversion Surgery

Urinary diversion is a way of surgically rerouting or diverting urine flow from its normal pathway in order to treat the condition of diseased or defective ureters, bladder or urethra, either temporarily or permanently. Using the surgical method of urinary reconstruction and diversion a new way is created for the patient to pass urine.
For all of the procedures, a portion of the small and/or large bowel is disconnected from the fecal stream and used for reconstruction.

Purpose

The bladder creates a reservoir for the liquid wastes created by the kidneys as a result of the ability of these organs to filter and retain glucose, salts, and minerals that the body needs.

When the bladder must be removed; or becomes diseased, injured, obstructed, or develops leak points; the release of urinary wastes from the kidneys becomes impaired, endangering the kidneys with an overburden of poisons.
Reasons for disabling the urinary bladder are: cancer of the bladder; neurogenic sources of bladder dysfunction; bladder sphincter detrusor overactivity that causes continual urge incontinence; chronic inflammatory diseases of the bladder; tuberculosis; and schistosomiasis, which is an infestation of the bladder by parasites, mostly occurring Africa and Asia.

Radical cystectomy, removal of the bladder, is the predominant treatment for cancer of the bladder, with radiation and chemotherapy as other alternatives.

Common Indications for Urinary System Diversion

• Cancer of the Bladder • Bladder Dysfunction due to Neurogenic Sources • Bladder Overactivity that causes Continual Urge Incontinence • Chronic Inflammatory Diseases of the Bladder • Neurogenic bladder conditions that threaten renal function • Severe radiation injury to the bladder • Chronic pelvic pain syndromes

Three Types of Urinary Diversion Surgeries

1. Ileal Conduit Urinary Diversion

The ileal conduit urinary diversion surgery is used in patients who have had their bladder removed and is usually used in conjunction with radical cystectomy in order to control invasive bladder cancer. In this procedure, the ureters are surgically unattached from the bladder and a ureteroenteric anastomosis is made in order to drain the urine into a detached section of ileum (a part of the small intestine). The end of the ileum is then brought out through an opening (a stoma) in the abdominal wall. The urine is collected through a bag that attaches on the outside of the body over the stoma. The bag must be periodically emptied of urine.

Procedure

Ileal conduit surgery consists of open abdominal surgery that proceeds in the following three stages: • Isolating the ileum, which is the last section of small bowel. The segment used is about 5.9–7.8 in (15–20 cm) in length. • The segment is then anastomosized, or grafted, to the ureters with absorbable sutures. • A stoma, or opening in skin, is created on the right side of the abdomen. • The other end of the bowel segment is attached to the stoma, which drains into a ostomy bag.

gesu_02_img0116-300x298 Urinary Diversion Surgery

Ileal Conduit Urinary Diversion Surgery (A). In a cystectomy with ileal conduit, an incision is made in the patient’s lower abdomen (B). The ureters are disconnected from the bladder, which is then removed (C). They are then attached to a section of ileum (small intestine) that has been removed and refashioned for that purpose (D). A stoma, or hole in the abdominal wall, is created at the site to allow drainage of the urine

2. Indiana Pouch Reservoir

indianapouch Urinary Diversion Surgery

In this form of urinary diversion, a reservoir (pouch) or a “false bladder” is constructed out of the right colon (large intestine) and a small segment of ileum (small intestine). The ureters are connected to the pouch and a short piece of small intestine is brought out to the skin as a small stoma. A one way valve mechanism is created so that urine is kept inside the reservoir (pouch) and will not leak out to the skin. Urine is removed by inserting a thin tube (catheter) into the stoma when the pouch is full. A bag is not required and the patient simply wears a bandage over the stoma. The patient is then taught to catheterize the reservoir to drain urine at regular intervals during the day. Although a continent diversion is not suitable for every patient who requires urinary diversion, it is an option to be considered.

3. Neobladder to Urethra Diversion

neobladder-urethra-diversion Urinary Diversion Surgery

With the Neobladder to Urethra Diversion procedure, the intent is to create a new bladder that mimics the storage function of a normal urinary bladder. The surgery makes a reservoir or pouch by utilizing a small part of the small intestine and connects the pouch to the urethra. The ureters are repositioned to drain into this pouch. As in normal urinary system, urine is able to pass from the kidney, to the ureters, to the pouch, and through the urethra out of the body.

Alternatively, a similar pouch called a neobladder may be created, attached to both the ureters and the urethra, in an attempt to preserve as close to normal bladder function as possible. In some patients, it is possible to safely connect a reservoir (pouch) made of small intestine to the urethra, allowing the patient to void in a manner similar to before surgery. The reservoir (pouch) is made to mimic the normal storage function of the urinary bladder. The patient is able to pass urine through the urethra, although there is a period of incontinence (leakage of urine) that all patients go through following this surgery. It may take some patients 12 to 18 months to regain control of their urination. A small but not insignificant percentage of patients will have persistent incontinence.

Rarely, a patient may not be able to empty this reservoir (pouch) well and will require intermittent catheterization (placement of a small tube into the urethra) in order to empty the reservoir (pouch). Some patients will be required to do this several times a day for a prolonged time period and in some cases permanently.

In order to be considered for this sort of reservoir (pouch) there must be no evidence of cancer at the urethra at the time of surgery, and patients must be willing and able to pass a catheter into the urethra to empty the reservoir (pouch) if necessary.

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